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The nurse is performing a skin assessment and notes a yellow tinge to the patient’s body. What is the term that the nurse will use to document this finding?

A nurse is caring for a patient with a Fentanyl (Duragesic) patch. She assesses the patient and finds him to be abnormally sleepy, is slurring words, has a glassy far away look in the eyes and is extremely unsteady when attempting to ambulate to the bathroom approximately 10 feet away. These signs/symptoms that the patient is exhibiting appear to be ones related to toxicity. What is the next priority nurse action?

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with acute myocardial infarction. The nurse notifies the physician of the finding which most likely suggests which of the following issues?

A client who resides in a long-term care facility has no family or visitors. Her only social contacts are with the staff. The client is confined to bed and is not able to communicate verbally. As part of the client’s care plan, the nurses provide massage therapy three times a week. What is the priority benefit of this intervention on the plan of care for this client?

An older client has an oral temperature reading of 96.8 degrees F and states they feel cold. Which interventions could help increase the client’s temperature? Select all that apply.

A patient has started Lasix (Furosemide) and the nurse is teaching the patient how to take this medication. Which of the following is the most appropriate teaching for this medication?

Which of the following is the most important measure after the nurse concludes that a patient’s goal has been met?

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful?

A nurse is educating a 65 year-old woman about Osteoporosis which causes bone demineralization. The nurse states that which change in diet can help reduce the risk of bone demineralization?

The nursing student is planning interventions for a patient with Acute Pain. Which of the following is an example of an appropriate well written intervention?